Interventional Procedures Consultation Document - Electrosurgery in tonsillectomy
NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE
Interventional Procedure Consultation Document
Electrosurgery for tonsillectomy
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The National Institute for Health and Clinical Excellence is examining electrosurgery (diathermy and coblation) for tonsillectomy and will publish guidance on its safety and efficacy to the NHS in England, Wales and Scotland. The Institute's Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisors, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about electrosurgery (diathermy and coblation) for tonsillectomy.
Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation. The process that the Institute will follow after the consultation period ends is as follows.
For further details, see the Interventional Procedures Programme manual, which is available from the Institute's website (www.nice.org.uk/ipprogrammemanual). Closing date for comments: 27 September |
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Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation. |
| 1 | Provisional recommendations |
| 1.1 |
Current evidence on the safety and efficacy of electrosurgery (diathermy and coblation) for tonsillectomy appears adequate to support the use of these techniques, provided that normal arrangements are in place for consent, audit and clinical governance. |
| 1.2 | Surgeons should avoid excessive use of diathermy during tonsillectomy. Surgeons using diathermy in tonsillectomy for dissection and/or haemostasis should be fully trained in its use and should understand the potential complications. |
| 1.3 | Use of coblation for tonsillectomy can result in higher rates of haemorrhage than other techniques and clinicians wishing to use coblation should be specifically trained. The British Association of Otorhinolaringologists - Head and Neck Surgeons have agreed to produce standards for training. |
| 1.4 | Surgeons should ensure that patients or their parents/carers understand the risk of haemorrhage after tonsillectomy using these techniques. In addition, use of the Institute's Information for the public is recommended. |
| 1.5 |
Surgeons should audit and review the rates of haemorrhage complicating tonsillectomy in their own practices and in the context of the techniques they use. Publication of further information about the influence of different techniques and other factors (such as age) on the incidence of haemorrhage after tonsillectomy would be useful in guiding future practice. |
| 2 | The procedure |
| 2.1 | Indications |
| 2.1.1 | Tonsillectomy may be used to treat recurrent or chronic tonsillar infection; tonsillar hypertrophy leading to respiratory symptoms or airway obstruction; peritonsillar abscess; and recurrent middle ear infection when tonsillar hypertrophy is believed to be an exacerbating factor. Life-threatening complications of these conditions are rare and the main aim of surgery is to relieve symptoms. |
| 2.1.2 |
Traditional 'cold steel' tonsillectomy consists of two stages: removal of the tonsil by sharp dissection followed by haemostasis. Pressure is initially used followed by ligatures to control any residual bleeding. Ligatures may be supplemented by diathermy and by the use of packs. |
| 2.2 | Outline of the procedure |
| 2.2.1 | Diathermy uses radiofrequency energy applied directly to the tissue, and can be bipolar (current passes between the two tips of the forceps) or monopolar (current passes between the forceps tips and a plate attached to the patient's skin). The heat generated may be used in dissection to incise the mucosa and divide the strands of tissue that bind the tonsil to the pharyngeal wall. It may also be used for haemostasis, coagulating the vessels that run in these strands and any other bleeding vessels. |
| 2.2.2 |
Coblation employs a bipolar electrical probe to produce a flow of sodium ions, which destroys the surrounding tissue. The probe is used to dissect the tonsil while cauterising blood vessels, which are identified using an operating microscope. Coblation heats surrounding tissue less than diathermy. |
| 2.3 | Efficacy |
| 2.3.1 | A systematic review of the published evidence on electrosurgery (diathermy and coblation) for tonsillectomy was commissioned by the Institute and completed in June 2005. |
| 2.3.2 |
Mean operating time across the 18 studies that reported this outcome was shortest for diathermy (mean 16.6 minutes), followed by cold steel with ligatures and/or diathermy haemostasis (mean 18.2 minutes). The longest time taken was with coblation (mean 24.5 minutes). |
| 2.3.3 |
Four studies looked at the time taken to return to a normal diet after tonsillectomy using diathermy versus cold steel for dissection. Three of the studies favoured cold steel (range 5-9 days for cold steel compared with 7-11 days for diathermy) while the fourth study favoured diathermy. Of two studies investigating the time taken to return to a normal diet after tonsillecomy using diathermy versus coblation, one study favoured diathermy (mean 6.7 days after diathermy compared with 7.4 days after coblation, p = 0.4) and the other favoured coblation (mean 2.4 days after coblation versus 7.6 days after diathermy, p < 0.0001). For more details refer to the sources of evidence (see Appendix). |
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| 2.4 | Safety |
| 2.4.1 |
2.4.1 Bleeding is an important complication of tonsillectomy. It can occur intraoperatively, during the first 24 hours after the operation (defined in most studies as primary haemorrhage), or after 24 hours (secondary haemorrhage). Postoperative haemorrhage may require readmission into hospital and possibly further surgery. |
| Primary haemorrhage | |
| 2.4.2 | Data from the National Prospective Tonsillectomy Audit indicated that the lowest rates of primary haemorrhage requiring return to theatre were associated with cold steel dissection with bipolar diathermy haemostasis; and with bipolar diathermy dissection and haemostasis (both 0.3%, 95% confidence interval [CI] 0.2% to 0.4%). The highest rates were associated with monopolar diathermy dissection and haemostasis (0.9%, 95% CI 0.3% to 2.3%), and with coblation (1.1%, 95% CI 0.7% to 1.7%). By contrast, data from the Wales Single-use Instrument Surveillance Programme (SISP) and data from the systematic review indicated that the highest rates of primary haemorrhage requiring return to theatre were associated with cold steel dissection with ligature haemostasis (1.1% and 0.9%, respectively). |
| 2.4.3 | Data from the National Prospective Tonsillectomy Audit final report on rates for all primary haemorrhage indicated that the lowest rates were associated with bipolar diathermy dissection and haemostasis, and with cold steel dissection combined with diathermy haemostasis. The highest rates were associated with coblation, and with monopolar diathermy dissection and haemostasis. For more details, refer to the sources of evidence (see Appendix). |
| Secondary haemorrhage | |
| 2.4.4 | In the England and Northern Ireland National Prospective Tonsillectomy Audit final report published in May 2005, that included 33,921 patients undergoing tonsillectomy, the lowest rate of secondary haemorrhage requiring return to theatre was associated with cold steel dissection with ligature haemostasis (0.2%, 95% CI 0.1% to 0.4%). Higher rates were associated with cold steel dissection with diathermy haemostasis (0.3%, 95% CI 0.1% to 0.7% with monopolar diathermy; and 0.4%, 95% CI 0.3% to 0.5% with bipolar). The highest rates of secondary haemorrhage requiring return to theatre were associated with coblation (0.7%, 95% CI 0.4% to 1.3%), and with diathermy dissection and haemostasis (0.7%, 95% CI 0.2% to 1.9% with monopolar diathermy; and 0.8%, 95% CI 0.6% to 0.9% with bipolar). Data from the Wales SISP and crude overall data from the studies included in the systematic review also suggested that cold steel dissection with ligature haemostasis was associated with lower rates of secondary haemorrhage requiring return to theatre, while use of diathermy for dissection and haemostasis was associated with higher rates. |
| 2.4.5 | A similar pattern was observed for all secondary haemorrhages (both those requiring and not requiring further operation). Lowest rates were associated with cold steel dissection with ligature haemostasis, higher rates with cold steel dissection and diathermy haemostasis, and the highest rates were associated with coblation and with diathermy for both dissection and haemostasis. For more details, refer to the sources of evidence (see Appendix). |
| 2.5 | Other comments |
| 2.5.1 | It was noted that the recommendations of the National Prospective Tonsillectomy Audit were that all surgeons undertaking tonsillectomy should be trained in the use of cold steel dissection and ligature haemostasis as well as being trained in the use of any electrosurgical techniques. |
| 2.5.2 | It was noted that it would be helpful for all diathermy equipment to record the total amount of energy used during each operation. The Medicines and Healthcare products Regulatory Agency is addressing this issue. |
| 3 | Further information |
| 3.1 |
The England and Northern Ireland National Prospective Tonsillectomy Audit was published in May 2005, and contains recommendations for tonsillectomy (https://www.tonsil-audit.org/documents/ta_finalreport.pdf). |
Bruce Campbell
Chairman, Interventional Procedures Advisory Committee
September 2005
| Appendix: | Sources of evidence |
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The following document, which summarises the evidence, was considered by the Interventional Procedures Advisory Committee when making its provisional recommendations.
Available from: www.nice.org.uk/ip_324review | |
This page was last updated: 31 January 2011